Okay, folks, good morning. We're going to get started here in this session. Okay, so this session, Department of Veterans Affairs Post Deployment Cardiopulmonary Evaluation Network or PDCEN, you're going to hear me say that quite a few times. So thank you for coming today. We appreciate you attending the session. More importantly, we appreciate everyone's interest in veterans' health. We have no disclosures to report as a group. The network, the PDCEN, is supported. Excuse me one second. Our slides did not advance on the big screen just now. AV folks, can you assist? It advanced on the speaker, presenter view, but it did not advance on the audience view. That worked. Let me try to advance one real quick. It doesn't look like it's matching up with – oh, may I try to go back? Looks great. Okay. Thank you, Dr. Teichman. Sorry. I'm seeing some familiar faces. This is my first time at AOHC, and it's good to be here. So no disclosures to report. The views that we'll express today are our own. So my name is Mike Falvo. I'm one of the co-directors of the Airborne Hazards and Burn Pit Center of Excellence. I'm a clinical exercise physiologist by training. I'm interested in mechanisms of dyspnea and exercise intolerance in the context of military and occupational exposures. I'm also a NIOSH spirometry course instructor and very interested in worker health and surveillance as well. I'm joined today by three colleagues, all of whom are pulmonologists. I'll start first with Dr. Stella Hines. She is our PDCN site director at the Baltimore VA. She's also an occupational environmental medicine physician, and what she hopes to cover today are some core clinical components of relevance to this audience. Dr. Sopha Kreft is also an occupational environmental medicine physician as well. She's going to use some case-based examples actually from patients we've evaluated within the PDCN to illustrate some of the components of the work and the complexity of the clinical presentation. And lastly, Dr. Anais Sotolongo, also a pulmonologist and a sleep medicine physician, our other co-director here at the Airborne Hazards and Burn Pit Center of Excellence. She's going to give you a quick snapshot of the PDCN, how it stands today, and where we're going. So I'm going to start first with an introduction. So Dr. Kreft and her colleagues published this great review paper several years ago now that talked about the variety of different types of conditions and illnesses that are reported following deployment. Some of those are summarized there in the bullet points to the right, and what you'll see here is kind of a variety of kind of common conditions, upper and lower respiratory conditions, but also some rarer conditions that affect the distal or smaller airways. Some of these conditions have previously been reported in a variety of other non-military occupational exposures as well. Now I think some of you in the room may have been able to participate this past Friday and Saturday in the two-day workshop of the preliminary program, so I won't spend a lot of time reviewing the different types of exposures that are in the deployment environment, but what I'll try to do is just summarize this real quick. That bar graph on the left-hand side is showing fine particulate matter at 15 different bases in the deployment environment, and suffice it to say that those levels are exceedingly high and exceed military environmental and national standards. The contributions to the high fine particulate matter include regional dust and sand, regional air pollution, as well as smoke from open burn pits, and so here's my plug to go listen to the Ockpod podcast that's associated with this. The recent episode is on burn pit exposure. We also think that veterans may be concerned, sorry, not concerned, but veterans may also be uniquely vulnerable and susceptible to these airborne hazards exposures for a variety of reasons really characterized by their military experience. So our center, the War-Related Illness and Injury Study Center, has been interested on these topics and more for over 20 years now, particularly these post-deployment health concerns, and I would say around the early 2000s, mid-2000s, our clinicians recognized an uptick in concern around exposures as well as respiratory complaints. This really led us to expand diagnostic testing in our approach to evaluating these veterans, and that ultimately culminated in establishing the VA Center of Excellence in 2019. Our approach is integrated with specialty clinical care, investigator-initiated research, and education, and we hope that one feeds onto another. At the Center of Excellence, we have five different kind of areas that we spend a lot of time on. Two that I'm going to talk about today are obviously the network, or the PDCEN, as well as the Airborne Hazards and Open Burn Pit Registry. So shortly after being established as a Center of Excellence, we realized we need to go find some like-minded folks to help us across the VA, because this is far too large a problem for one center to tackle. So we established this post-deployment cardiopulmonary evaluation network, and we're looking specifically for some physician scientists that were interested in this area, had expertise around pulmonary medicine, as well as occupational environmental medicine, had an active research program, and a really strong affiliate, because what we want to do is to be able to kind of train and engage those kind of across the system in and out of the VA. Currently we have six sites. These are spread across the country, San Francisco, Denver, Nashville, Ann Arbor, Baltimore, and our home in East Orange, New Jersey, and you can see our colleagues that are listed here. With respect to our mission, it is focused on a standardized clinical evaluation, and everything really stems from that. So what our network hopes to do is to be able to provide clarity around diagnoses, where appropriate, understand the relationship to those conditions and their exposures, and what we are working on very rigorously is trying to build research around that, and then disseminate some best practices, and you'll hear a little bit about that at the end of the talk today. Now I think it's important to describe the Airborne Hazards and Open Bird Pit Registry, national registry that's open to service members and veterans. As of last month, over 380,000 were enrolled. This registry consists of two primary parts. It includes a self-assessment questionnaire, symptoms, exposures, military experience, and it also allows a service member or veteran to request an optional in-person health evaluation, and it's there at which we identify the veterans that are evaluated as part of the PDCM. Okay, so this looks like a busy slide, and I'm going to walk you through this. So 10 steps on how veterans that are in the registry can get to one of the PDCM sites. Let me go through the first five. So these are really on the part of the veteran or the service member. As we're within the VA, we're going to focus on the veterans, of course. So obviously we need to complete the registry. Step two, the veteran needs to be enrolled in VA care. They need to request an in-person health evaluation. That's number three there. Number four, we're going to evaluate their self-assessment questionnaire to make sure that they're endorsing respiratory symptoms. And then number five, we're going to look to see if there are some type of respiratory condition that they've reported, whether that's an obstructive, restrictive type of condition or perhaps something rarer. After we go through those first five steps, the next five steps are really at our center and across the network. So using that kind of delimited sample, we then try to identify veterans that are in close proximity to one of those six sites. Our local PDCN coordinator at one of those sites then invites a veteran through mail and then follows up with a phone screening and then ultimately schedules for a multi-day multidisciplinary evaluation at one of those sites. So those are the 10 steps. I try to make it kind of brief. So ultimately at the end of the day, what we hope to be able to learn from is this clinical experience. So as I mentioned earlier, our network is founded around a standardized comprehensive clinical evaluation. You're going to hear Dr. Hines talk about that in a second. And really it's making sure that we're collecting the variables of interest to then hopefully disseminate some of those best practices and lessons learned. I'm going to turn it over to my colleague now, Dr. Hines. Thank you very much, Dr. Falvo. So next I will highlight how we evaluate these patients. And really what I want to do is point out how some of the tools that we use are also relevant to occupational medicine evaluations. And for any of the current or former UCSN Hopkins residents in the audience, there will be a test because you guys have done all of this. All right, so as Dr. Falvo mentioned, this population may be at increased risk for a variety of respiratory conditions. Now some of these are very difficult to diagnose, such as constrictive bronchiolitis. But even conditions that may seem simple to diagnose, like asthma, can actually be quite challenging in the absence of a structured evaluation. So these kind of conditions and diagnosis could be missed without that process. So we use multiple modalities involving multiple disciplines to clarify diagnoses in this symptomatic population. So the evaluation starts with collection of several validated symptom questionnaires. And most of these are focused on the aerodigestive tract. Everyone goes through history and physical examination, and there's a battery of laboratory tests that we collect, including labs that evaluate for autoimmunity. We assess military and non-military occupational and environmental exposures, but we are assisted by use of a series of questionnaires that were originally designed for use in a VA Cooperative Studies Program shade research study, which is headed by Dr. Eric Garchick at the Boston VA and Paul Blanc at the San Francisco VA. So these questionnaires provide semi-quantitative assessment of multiple domains, as you see here, multiple sources of smoke, dust, exhaust, and et cetera, including smoking and other kind of environmental and hobby-based exposures. So through this shade module, we also collect location and time data for each of these individuals that can be ultimately linked to satellite data providing aerial optical density that can be correlated to an assessment of particulate matter exposure. So we're very fortunate that we're able to use kind of what's a research tool as part of clinical practice, and we're very thankful to Dr. Garchick and Dr. Blanc for sharing this. All right, we perform multiple pulmonary physiological tests. So this audience I know is very familiar with spirometry, but there's a limit to how much spirometry can tell us. So full-study PFTs include lung volumes and diffusion capacity as well. Lung volume measurements tell us a little bit more about lung mechanics. For example, someone can have evidence on lung volumes of air trapping or hyperinflation that actually might not show up as obstruction on spirometry. And the diffusion capacity tells us about the gas exchange properties of the lungs that spirometry is not going to tell you about. So where PFTs are used in occupational medicine kind of routinely is in the determination of impairment ratings, where both the spirometry and the diffusion capacity values play roles in getting to that total impairment assessment. And of course, the use of pre- and post-bronchodilator spirometry is part of the diagnostic workup of asthma. We perform bronchoprovocation testing using the nonspecific irritant methicoline. So this test, kind of like a pulmonary stress test, tells us about airway hyperresponsiveness, which is a key component in asthma. And this test can be positive even when spirometry does not show airflow obstruction. Thus, relying exclusively on spirometry can miss an asthma diagnosis. The result of this test is something called a PC or PD20, representing the concentration or dose of methicoline at which the FEV1 falls by 20%. So bronchoprovocation testing is used in traditional OCMED as part of the diagnosis of asthma, in certain workers' compensation evaluation recommendations, and in the evaluation of certain occupational groups, such as firefighters. And that final result, the PC20, is also a component used in impairment ratings for asthma. The next tool, the cardiopulmonary exercise test, or CPET, allows us to identify abnormalities that only show up on exertion. So this is a tool used to assess unexplained dyspnea, and the outcome we get from a CPET is exercise tolerance, which is indicated by the measure VO2, or oxygen consumption. So we then determine what is limiting the exercise tolerance. Is it a cardiovascular abnormality? Is it a ventilatory abnormality or lung mechanical problem? Is it a gas exchange abnormality? Or is it a problem with the muscles, such as deconditioning or a mitochondrial problem? So CPETs are used in OCMED. Usually they can be as a component of impairment ratings, again, for parenchymal disease, where the VO2 plays a role in the categorization. CPETs can be used for fitness for duty, and have been recommended as part of the medical surveillance of certain populations, such as firefighters. We measure FENO, which stands for fractional exhaled nitric oxide. So often used by allergists or asthma specialists, this is a test that detects eosinophilic inflammation and gives an indication of whether that person may have a steroid-responsive condition. So FENO has been recommended by ACOM in the work-related asthma guidelines for monitoring of patients with asthma and in certain circumstances for a diagnosis of asthma. So a test that may be particularly helpful in identifying problems of the small airways, such as constrictive bronchiolitis, is oscillometry. So this test uses a different technology than PFTs by superimposing sound waves over normal non-forced tidal breathing. And as a result of this, it is less effort dependent, and you can also use it to determine a bronchodilator response. So this test tells us a couple things. It tells us about total airways resistance, but then you can break it down into central airways resistance versus airways resistance at the small airways or distal lung, which typically is very challenging to assess with spirometry, and spirometry may not even be capable of assessing that part of the lung. So it can also tell us a general assessment of what I'll say is lung stiffness through a measure called reactance. So oscillometry has been used in occupational medicine, in medical surveillance, and in research applications of certain populations. It's been used in World Trade Center, dust-exposed population follow-up, and in flavor workers. And I think, importantly, one of the early studies in World Trade Center showed that there was good correlation between impulse oscillometry results and symptoms, whereas that correlation was not present with spirometry. All right, chest imaging is very important in this population, but it must include high-resolution images with expiration, which is not a normal part of a regular old CT. So certain conditions, such as small airways disease and tracheobronchomalacia, may only show up radiographically during the act of exhalation. So as you can see here in this CT scan, which is from a patient with a biopsy-confirmed constrictive bronchiolitis, on the inspiratory CT scan, it looks normal. But on exhalation, you see that there are these areas that look much more black next to areas that are much more gray. And that indicates air trapping in the areas that are black. And you would not see this unless you also ordered the expiratory images. So very important. So this tool is also used in OCMED to evaluate parenchymal conditions like hypersensitivity pneumonitis. All right, finally, we evaluate the upper airway using sinus CT, as well as direct fiber optic laryngoscopy with video stroboscopy to look for inducible laryngeal obstruction, which can manifest as dyspnea. We also perform in-lab sleep study to evaluate for sleep disorders, which can manifest as fatigue and exercise intolerance. And we also assess the cardiac function using echocardiography in addition to the data we get from the CPETS. So once we've completed all of this, we synthesize our findings to render a diagnosis and try to correlate that diagnosis with the relevance of the exposures to that diagnosis. With challenging cases, we discuss them in a network in a virtual case conference, which case conferences kind of become a standard of care in the pulmonary world for complex diseases like interstitial lung disease. So thank you for your attention. I'm gonna turn this over to Dr. Kreft, who is now gonna show examples of how we put these tools together. Thank you, Dr. Hines. Over the next few slides, I'm gonna take you through a couple of case examples from the PDCN. So let's begin with our first case. So we have a 35-year-old male nonsmoker who presents with longstanding shortness of breath. And this started after his second deployment to Afghanistan. He had reported his symptoms to his provider more than seven years ago, but was told his lung function was normal. He also experienced nasal congestion, shortness of breath at rest, and with exertion, with chronic nonproductive cough. His exposure history was notable for desert dust, sandstorms, burn pits, and diesel from vehicles. His vitals and physical exam were within normal limits. So he went on to have pulmonary function testing. And as you can see here on this slide, most of these measurements are greater than the lower limit of normal. So ultimately, his pulmonary function testing was normal. He had normal spirometry without any evidence of airflow limitation. And although not shown here, there was no significant bronchodilator response. Lung volumes and diffusion capacity of carbon monoxide were also normal. He also went on to have forced oscillation testing, which Dr. Hines had introduced to you all. And that also was normal, with no significant reduction in airway resistance with bronchodilator administration. He went on to have a high-resolution chest CT scan with prone and expiratory images, also, again, unremarkable. So in terms of other testing he underwent, included sinus CT scan, which was significant for extensive sinus disease with bilateral mucosal thickening and partial opacification of frontal sinuses, but didn't really explain his shortness of breath. He also had an EKG and a cardiac ultrasound that were both within normal limits. Apart from his sinus CT scan, everything else had been normal in this particular patient, except for an elevated serum IgE concentration that was over 1,000. And then he also, although his CBC with differential was normal at this time, had had a history of a relative peripheral eosinophilia. So at this point, we're stuck with someone who has longstanding shortness of breath with a sinus CT scan that shows extensive sinus disease and evidence of Th2 inflammation with this high IgE and history of eosinophils. So as Dr. Hines had mentioned, we made the decision to refer this patient to the Methylcholine Challenge. And he also underwent a laryngoscopy at the same time. And that was significant for airways hyper-responsiveness. So you can see here that his Methylcholine Challenge showed that his FEV1 dropped by 20% at a concentration of 2.62 milligrams per milliliters of methylcholine. Right before he had his bronchodilator administration, he also underwent laryngoscopy and did not show any evidence of inducible laryngeal obstruction, also sometimes referred to as vocal cord dysfunction. So his final diagnosis included asthma and chronic rhinosinusitis. So this case really highlights how somebody with persistent unexplained dyspnea went undiagnosed and having that Methylcholine Challenge really tied together his lab abnormalities and symptoms. So just think about that in your diagnostic evaluation if you're running into some problems with just general lung function testing. So moving on to our second case, this is a 31-year-old ex-smoker with three and a half pack year smoking history. He presented with shortness of breath. Oh, sorry. So he had symptoms of lung burning, sensation, and nasal congestion that started during his deployment. He had persistent dyspnea even after his deployment and really had noticed this lifestyle change. His main concern was that this was impacting his ability to go hiking with friends. His oxygen saturation, which previously had never dropped at elevations of 8,000 to 10,000 feet, was noted to be 85%, and his friends were just, frankly, scared to go exercise with him. In terms of his military and deployment history, he had served as part of the military police. He had a 12-month deployment to Southwest Asia, and he noted exposures to burn pit smoke, five to six sandstorms during his deployment, diesel exposures and vehicular exhaust during daily patrols, and then also was exposed to a blast where he actually experienced loss of consciousness. There's lots of dust in the vehicle, and he was on concussion protocol for three days. So a lot of exposures there. And then moving on to his diagnostic testing, this may be difficult to see here, but his pulmonary function testing shows that his FEV1 and FEC are actually both greater than the lower limit of normal, but his FEV1 of 71% is slightly below the lower limit of normal of 73%. And although not shown, there's no significant bronchodilator response. His lung volume showed some air trapping, being greater with his RV greater than the upper limit of normal, and his diffusion capacity was normal. He also underwent a bronchial challenge that did show borderline airways hyperresponsiveness to methylcholine at a provocative dose of 0.72 micrograms of methylcholine. He subsequently underwent a continuous video laryngoscopy with exercise, which is basically an exercise test where he also has a continuous video laryngoscopy. And that did not show any evidence of inducible laryngeal obstruction. And as Dr. Hines had mentioned, the utility of CPAT, especially as you noted, he had reported some symptoms, or some low oxygen saturations. He underwent a cardiopulmonary exercise test with an arterial line that showed that he had normal exercise capacity based on VO2 max, but he had a drop in his pulse ox, as well as a drop in his arterial oxygen saturation with exercise, which is definitely not a normal response to exercise. So moving on, his high resolution chest CT scan was significant for diffuse air trapping. And his final diagnoses were asthma and bronchiolitis, also referred to as small airways disease or distal lung disease. So the asthma we established with his abnormal methicholine challenge, but the small airways disease was established by this air trapping that's noted on CT. So if you look at the top arrow, you'll see that it's pointing to this more black area, a more lucent area, which indicates more air. And then the bottom arrow is pointing to, it may be hard to see on the screen, but a more gray area. So this is that mosaicism that Dr. Hines was speaking about. And this type of mosaicism is typically not seen in asthma. And especially the drop in the arterial oxygen saturation during exercise, also not consistent with asthma. And so that is what helped us get to this diagnosis of small airways disease without having to put this patient through a surgical lung biopsy. So again, showing the utility of a high resolution chest CT scan with expiratory images and cardiopulmonary exercise testing. And then moving to our last case, this is really just an imaging example. We had a 44 year old male never smoker with unexplained shortness of breath. He had deployed to Southwest Asia three times as a firefighter in the Air Force. And he had non-diagnostic testing, but he did undergo this high resolution chest CT scan with dynamic expiratory imaging. And this is what it showed. So you can see that on the left panel, the CT demonstrates a lunate appearance of the trachea. So normally the trachea on an axial CT like this should look like a circle, but you can see that it's kind of already abnormal. But then on the expiratory image, you can see that it significantly collapses the anterior and posterior membrane there, consistent with tracheobronchomalacia. And so this expiratory CT helped us explain otherwise symptoms that were out of proportion to testing. So ultimately this dynamic expiratory CT established a diagnosis of tracheobronchomalacia with greater than 90% tracheal collapse. So I'm gonna pass it along now to Dr. Sotolongo. Thank you, Dr. Craft. And thank you all for taking time out of your busy day to come to this presentation. So I'm gonna talk a little bit about the PDCN as a whole, where we are and where we're going. Just a quick overview of the many sort of avenues that we like to look at as part of the PDCN. From a clinical standpoint, if you go by the numbers, right now over the last three years, we've reviewed about 1,400 charts. We invited about 300 or so veterans and those who accepted, we did 216 phone screens and scheduled about almost 200 to come in for a comprehensive evaluation. Unfortunately, during this time, there was a little something called a pandemic. So we had to put a bit of a pause on bringing people in. Although we are starting up again. So of the people that were scheduled, we were able to do about 127 initiated questionnaires and of those about 121 were completed. And of those, then we were able to get 93 veterans in for a at least partial or complete evaluation. So when we do a deeper dive in those 93, we had them at about, in their mid 40s, there was about a five to one male to female ratio. Their BMI was in the low 30s and they had overwhelming complaints of or concerns regarding shortness of breath, at least moderate to severe shortness of breath, which is not surprising since we selected these veterans because of respiratory issues. And then the breakdown, the demographic is more or less what you expect that reflects the military as a whole. So when we look at their exposures, they'll suffer supported exposures, again, very much into respiratory irritants with burning trash, which included the burn pits, certainly sand and dust storms, again, not surprising given the deployment area and also a lot of burning vehicles and explosions were sort of the top three irritants that they were self reported. So from an outreach or education point of view, the PDCN was trying to fill, avoid or answer the question that many veterans and providers had. And that is where can we get information regarding airborne hazards, including the burn pits and possible respiratory effects of those airborne hazards. And so what we try to do is some of the things that we did over the last few years was to put together a fact sheet that patient friendly fact sheet is printed through the American Thoracic Society. We also do, we did a national virtual listening session. So we did it over a period of about four months in which we would have, we would be invited veterans to a virtual listening session in which they told us some of their concerns and what they could do about it and what we knew at the time with regard to airborne hazards and we also do this by, we also do education outreach by doing webinars and presentations like this. We also wanted to have a say or try to help in clarifying some of the controversy that's out there and try to have people understand what we know about certain diseases and I think one of the examples that we worked on over the last couple of years was constrictive bronchiolitis. For those of you who may not know the controversy of constrictive bronchiolitis, I'll do a quick recap of the history. So in 2011, Dr. Robert Miller looked at or evaluated 80 service members who had reported shortness of breath, unexplained dyspnea, despite evaluation or diagnostic testing or to have had, yeah, diagnostic evaluation that was, did not really give a diagnosis and of those 80, 49 underwent lung biopsy and of those 49, 38 had a diagnosis of constrictive bronchiolitis and 11 had an other diagnosis such as sarcoidosis, hypersensitivity pneumonitis or respiratory bronchiolitis. Well, this started, again, this sort of started a controversy, some of the questions that flew among pulmonologists, op med doctors and so forth was, well, number one was that there was a question about whether the criteria for diagnosing constrictive bronchiolitis was correct and there was controversy with guarding that. The other controversy or the other concerns were from providers who were very reluctant to refer their patients for lung biopsy with all its ensuing risk for what they felt were normal testing and nothing that they could really see on CAT scans and then the other part of that, the other side of that was the veterans or service members who were very frustrated and that they were concerned that they were having these respiratory issues. It seemed like there was an answer as the diagnosis would be constrictive bronchiolitis yet they felt there was a reluctance on the part of clinicians and the VA as a whole to recognize this disease. In 2020, the NASM, the National Academy of Science, Engineering and Medicine put out a report and they highlighted or put into their report the controversy of constrictive bronchiolitis and that they recommended that the VA convene a panel of experts. And on that, based on that recommendation and also the fact that we were thinking about this prior to that, we convened a panel in 2021. We went through a modified approach. So again, just in terms of the timeline, the NASM report went out in 2020 and then we spent some time trying to gather the subject matter experts as well as create sort of the structure in order to be able to come up with a consensus. Over the course of the next several months, we had several meetings, both small groups and larger groups, I call the summit, to go over statements or what we knew regarding not just constrictive bronchiolitis, but in general, respiratory-related issues that veterans and service members were undergoing. And over the course, again, over several months, we were able to consolidate the statements and put together and edit the statements and put together a group or a consensus in which we felt that there was overwhelming agreement on. And that resulted in a consensus statement and a manuscript that was published in CHEST. And just to give you a breakdown of the, sort of the demographics, if you will, of the panel, they were about 45% were from the VA, of which 40% were also PDCN members. We had members from the Department of Defense. We also had members from academia, as well as other sessions or other parts of the federal government, like the CDC. The breakdown of specialties were pulmonologists, occupational and environmental medicine physicians. We had radiologists and we had pathologists as well. And they've had a fairly extensive experience with not only deployed service members, but also with constrictive bronchiolitis. So the summary of the consensus was that it really was not helpful to just focus in on constrictive bronchiolitis. The consensus was that exposure, deployment-related exposures, airborne hazards exposures, can affect any part of the respiratory tract, including anywhere from the sinuses all the way down to the small airways, which does include constrictive bronchiolitis. So we prefer or we recommend not using, just saying yes or no with regard to constrictive bronchiolitis, but to have a more of a total, expansive diagnosis of deployment-related respiratory diseases. Because again, a service member can have multiple conditions affecting their respiratory tract. And to simply say, well, yes, you do have constrictive bronchiolitis, or no, you don't have constrictive bronchiolitis, doesn't really address the fact that there may be some effects of their deployment. The other aspect of the manuscript is that we developed a provider toolkit. Again, this is for providers who aren't quite sure how to start a workup. We recommend a stepwise approach to an evaluation of a veteran or a service member who has shortness of breath and was deployed to Iraq or Southwest Asia in that area. It starts off as any good evaluation starts with a history. We focus in on also not only the history of when, where, how, but also in terms of their exposures, their military exposures, as well as their non-military exposures. If you have, we do know that not everyone is an occupational environmental medicine doctor, so what we have in the toolkit, in this foldable printable toolkit is a QR code and so you can scan that code if you had any questions or were concerned about well am I asking the right questions and hopefully that will be helpful. Once you've done the history and physical then there's I said a stepwise approach to having patients diagnostic evaluation so starting it start with imaging PFTs so forth if you have a diagnosis of asthma or rhinitis obviously you treat as you would any diagnosis of asthma or rhinitis but if again there's still some concern you move up to sort of the next level looking at comorbidities and also within this toolkit there's a point in which we do recommend maybe referral to a tertiary care facility for more in-depth evaluation so again the point of the toolkit is to serve as a resource for providers who may not know exactly what to do and where to start and then looking forward what we continue to do and with with journal clubs and case conferences is to consolidate some of the information that's out there in order for us to hopefully educate and do outreach we're looking for different diagnostic approaches hopefully non-invasive we are looking to uptick on our research we're working on creating cohort of controls in order to compare controls to the veterans who report symptoms and see where their similarities and where there are differences as well as continuing to understand what kind of diseases are out there that service people are suffering from due to or associated with their deployment there's a quick slide on where you can get more information certainly our website and certain publications such as in the federal practitioner and so forth and then I want to acknowledge that it takes a village it truly does in terms of not only do we have the six PDC and sites but within each site there are several people who help support that and help support the veterans and then these are some of the web resources that if you want more information you can certainly click on and we'll take you to the links and with that I will end and hopefully open up for questions thank you okay yes we welcome questions it's kind of bright out here so if I don't see you speak up all right Dr. and I think that is it's not on that sounds good oh that's true thanks that's Dr. okay great now it's echoing based on my experience after having you know worked for many decades some people that have symptoms no matter what kind of workup you do you don't find a physiologic cause now the cases that you showed I'm guessing but I don't know that they may be the minority and that there are a lot of a lot of patients that have symptoms where the exhaustive workup does not provide like a physiologic diagnosis is that accurate that's question one I have a follow up yeah I'll comment and then I think any of us could also provide our own experiences with this through since doing these veteran evaluations there's always something I've been able to find and that can be a contribution to their symptoms but there definitely are patients we see where maybe we don't see something but I think in contrast to maybe what has been billed I think that's the minority and not the majority anybody else kind of want to comment on that yeah I don't think we have another mic just for the table I do agree that you may not find sort of one unifying sort of diagnosis it says okay this is a cause of all your symptoms I do think though that you can sort of parse out some things in which you can improve the veterans sort of overall health so so that's what I would say yes absolutely there's not I think the minority of getting sort of one unifying diagnosis is that is probably as you said the minority but I do think you can sort of take small parts of what could be affecting their overall health and help with that thank you and this is the follow-up question if I might is are you looking you said psychiatric but are you looking at all for work work disability risk factors like symptom catastrophizing injustice experience adverse childhood experiences because all of those could be things that that kind of moderate the the symptoms and lead to more functional impact and might be treatable with non kind of pulmonary approaches yeah so we do an emotional health questionnaire as part of the evaluation it does not get at some of those additional details like early childhood adverse experiences but I think we all appreciate that that the emotional health absolutely intersects with the experience of fatigue and dyspnea and so there are more things that I think we could incorporate in the future to be able to fully evaluate that even further thanks dr. Helmer yeah drew Helmer I'm with the VA in Houston and formerly colleagues of these fine folks giving this presentation it was excellent and I really appreciate the update I think kind of along the same theme I wanted to hear a little bit more about the diversity of the diagnoses that you're detecting as part of the PDC and maybe you have a publication coming out where you're gonna report that if you know but how common are some of these findings I mean some of the examples you gave are maybe kind of the classic enigmatic you know worrisome conditions but are they typical of the 93 people or are they less typical I know you don't have a population based approach and then and then I want you to also address the discrepancy between what I suspect is a pretty diverse experience of these conditions these actual diagnoses these contributing factors and what you call deployment related lung disease without an S and they know I have a problem with that all right dr. craft is going to take that on okay there's a lot of questions there so I'll start trying to answer some and then hopefully you can remind me or other people can kind of jump in right we we don't really have a typical population based approach like with you know the scientific rigor in in the sense of the patient population we're seeing because most of these patients are referred to us with symptoms so already there's like a self-referral bias there I can talk to our experience from both the PDC and because for our PDC and patients at eastern Colorado are referred for subspecialty evaluation for those difficult to diagnose conditions where they've seen multiple providers but we also have just a subspecialty evaluation where maybe we don't do all the testing in a multi-day process but we're do a lot of the PDC and evaluation but over a longer period of time and I would say that now in our you know in our cohort we have over 600 patients that we follow like we evaluate them and they continue to follow in our clinic most of these are people who have deployed in the post 9-11 era and some of which also have had first Gulf War exposures as well I would say that we have less than a hundred that are exclusively first Gulf War era but most but most are you know I can in that post 9-11 era I I don't have these numbers yet but at least in our sample we will be publishing what the prevalence of these you know of these diagnostic conditions are and I think anecdotally my gut is telling me at least 50% have asthma you know and many methicolene challenge testing has been helpful in a good percentage maybe about half of our methicolene challenges are negative sometimes we do the methicolene challenge and laryngoscopy not so much for the airways hyper responsiveness but to also induce symptoms or recreate symptoms that we can't get during general lung function testing that might be helpful to identify upper airway dysfunction so that's a little bit of what we're seeing we also are seeing a fair amount of both th2 high and non th2 or teach to low asthma when we think about like endotypes and phenotypes and then to get to your question about deployment lung disease maybe not the deployment respiratory disease I you know I've struggled with some of that like is there something that makes it uniquely deployment you know and I I think that maybe future research will help us identify you know differences and mechanisms of injury and inflammation but the way we've approached it which I think is a way we approach it a lot in occupational lung disease is identify a diagnosis and then address causation so I think of it as this meets diagnostic criteria for asthma and we also have this distal lung disease so this is where we're seeing bronchiolitis granulomatous lung disease that doesn't quite fit a picture of hypersensitivity pneumonitis and also emphysema in the kind of COPD spectrum sometimes with obstruction and sometimes without obstruction but not always radiographically present or not always visible on chest imaging so those are the lung disease I think primarily airways I am not seeing a ton of parenchymal lung disease that's evident on chest imaging but may be detected on lung biopsy you know we are doing fewer lung biopsies I think that when people have relatively preserved lung function although we're not sure where they started from they are not exactly keen to you know undergo a lung biopsy and I think having the reassurance that they're going to be followed with longitudinal lung function testing or symptoms is somewhat reassuring so that we can pull that trigger if they truly have a decline so that's I don't know if I answered everything but maybe a start and maybe just just real briefly dr. I guess one thing I would add to as the non-physician but from a research perspective to and what we're trying to do is describe what we see and there's a few different approaches that we're trying to use now based on the totality of all those different types of physiological testings that dr. Heinz winter on kind of where they might cluster and what that might tell us so although yes we have to kind of address the clinical presentation and assignment diagnosis I can't speak to anything about that what we do try to do is describe what we see and hopefully understand some of those features thank you for the question great dr. Hodgson great presentations thanks two questions the first why do why do people think yeah why do people think how and why trachea malaysia isolated trachea malaysia can happen and a second then about symptoms in the presence of no known physiology abnormalities with say bronchiolitis or some air trapping there's some old literature on the sensation of dyspnea and opiate receptors and whether anybody has tried low-dose opiates around symptom management I'll make a first comment and then I think some of just kind of the thought about why don't you see physiologic manifestations when they're so symptomatic so some of this may be we don't have the right tools to be able to assess whatever that physiologic processes that leads to dyspnea so that may be part of it I mean I think obviously the other thing people say well maybe there's nothing actually there but I think you know there's other sessions here that really emphasize that the total experience of a symptom is probably not related to just one specific body part and so I think that may be a component I'll offer to the question about tracheal bronchomalacia related to why this population might get that but I'll let dr. Kraft answer that I think that's actually an excellent question and I don't really know the answer but in a paper that we published a few years ago in the Journal of Thoracic Imaging we speculated after doing a little bit of a literature review I mean when we think about tracheal bronchomalacia we typically see that in patients with you know severe persistent uncontrolled asthma or obstructive lung disease or that's what I've typically seen in my older VA patient population but I think that we may be missing that diagnosis with or under appreciating the true prevalence of tracheal bronchomalacia and there's also debate about what types of cutoffs to use but it may be more present than we we understand but in terms of the standalone tracheal bronchomalacia there was a paper that was published in the American Journal of Respiratory and Critical Care Medicine several years back going back to Iraq and Iran war civilians who were affected by sulfur mustard who had the appearance of isolated tracheal bronchomalacia you know in the absence of other you know severe like asthma or other kinds of obstructive lung disease some were associated with bronchiolitis thought to be due to that sulfur the the sulfur dioxide exposures but we don't we don't truly know there's also some case reports in the literature about individuals who have vaped and appear to have tracheal bronchomalacia as well so some so I don't really know the answer like whether it is direct injury that's happening to the not necessarily cartilage but also the posterior membrane of the trachea from an injury or if it's actually that there's distal lung disease with increased small airways resistance that is also contributing to the collapse so those are some of the theories but I don't think we have a true understanding of that thanks and he had asked about the opioid receptor anyone want to comment on that I just want to comment I think that is an interesting thought I mean again this is anecdotally most of the patients that I evaluate and you ask them to take in a deep breath they will do shallow breathing or they worry because they're gonna start coughing uncontrollably so when you think about the opiate receptor I think that is interesting I mean this is how we manage things in bronchoscopy at least you know with the coughing I I don't know that anyone has really looked into that or treating with low dose opioids especially given terms of risk I have what I have done in other workers comp cases where people have had significant airway injury where they seem to have some impact on the nociceptor is used nebulized lidocaine you know kind of an off-label use obviously that that has not been something that I've been able to get at the VA but I think there's that's just an interesting thought you know in terms of there's inflammation but there may also be this injury and this and this cough receptor a part that we need to be thinking about as a target of therapy in the future and there was I just remember years ago a New England Journal paper where they used five milligrams of codeine to treat the subjective isolated symptom and so I've seen anything since thanks yes oh hi everyone I'm Manny Berenji from VA Long Beach we're actually fielding questions from our virtual participants I'm hoping we have a little bit of time to help these folks out with their questions so first off we have a beer to Garcia he had a question regarding do you all have an idea of toxicants exposure dose level correlated to the levels of pathology on your screening diagnostic tests so I think actually do you want to comment on that in terms of our PDC in exposure metrics I'll make a comment I think our other participants can probably weigh in too so I had mentioned and one of the tools that we use is this exposure module where we can get these semi quantitative assessments of all the different modalities and so I think maybe not yet but the goal is for us to be able to see how much exposure as reported in this population can correlate with some of these outcomes and in the future how much estimated particulate matter exposure can correlate with these different pulmonary outcomes from symptoms to test abnormalities yeah I think to add to what dr. Hines is saying we are in we are in the process or to try to do that to quantify that that also helps with maybe getting cohorts of controls so that we can compare maybe symptoms with exposure and so come up with maybe for lack of a better term an exposure score that maybe says if you have above this then chances are you're going to have some sort of symptom so we are in the process and then I had a comment from one of our virtual participants David Lewis he states sounds good but as a former military doc we routinely had some significant mismatches between good support staff and spirometers but makes a lot of sense thanks thank you thank you for raising those questions we can't see it all right we are at time thank you everyone for coming and hopefully take this back to your communities so that they know this is happening within the VA thank you very much

respiratory health

airborne hazards

burn pit exposures

diagnostic tools

pulmonary function testing

asthma

chronic rhinosinusitis

small airways disease

emotional health

constrictive bronchiolitis